JEEVANDAN
(CADAVER TRANSPLANTATION PROGARMME)
Government of Telangana
APPLICATION FOR THE REGISTRATION OF NONTRANSPLANT ORGAN
HARVESTING CENTRES (NTOHC) FOR DECEASED ORGAN DONATION
To
The Appropriate Authority for deceased donor organ
transplantation_________________________ (State or Union Territory)
We hereby apply to be recognized as an institution to carry out deceased
donor organ harvesting. The required data about the facilities available in
the hospital are as follows:-
(A) Hospital:
1. Name ____________________________________
2. Location ____________________________________
3. Govt./Pvt. ____________________________________
4. Teaching/Non-teaching ____________________________________
5. Approached by:
Road: Yes No
Rail: Yes No
Air: Yes No
6. Total bed strength: ____________________________________
7. Name of the disciplines ___________________________________
in the hospital
8. Annual budget ____________________________________
9. Patient turnover/year ____________________________________
(B) Surgical Team:
1. No. of beds ____________________________________
2. No. of permanent staff ______________________________________
members with their
designations
3. No. of temporary staff ______________________________________
with their designations
4. No. of operations done _____________________________________
per year
5. Trained persons available ____________________________________
for transplantation (Please
specify organ for transplantation)
(C) Medical Team:
1. No. of beds _____________________________________
2. No. of permanent staff
members with their _____________________________________
designation
3. No. of temporary staff
members with their _____________________________________
designation
4. Patient turnover per year ____________________________________
5. No. of potential transplant
candidates admitted per ____________________________________
year
(D) Anaesthesiology:
1. No. of permanent staff ____________________________________
members with their
designations
2. No. of temporary staff
members with their ______________________________________
designations
3. Name and No. of
operations performed ______________________________________
4. Name and No. of
equipments available ______________________________________
5. Total no. of operation
theatres in the hospital _____________________________________
6. No. of emergency
operation-theatres _____________________________________
7. No. of separate transplant
operation theatre _____________________________________
(E) Neurosurgery:
1. No. of beds ___________________________________
2. No. of permanent staff _________________________________
members with their
designations
3. No. of temporary staff __________________________________
with their designations
4. No. of operations done __________________________________
per year
5. Trained persons available __________________________________
for transplantation (Please
specify organ for transplantation)
(F) Neurology:
1. No. of beds __________________________________
2. No. of permanent staff
members with their ___________________________________
designation
3. No. of temporary staff
members with their ___________________________________
designation
4. Patient turnover per year ___________________________________
5. No. of potential transplant
candidates admitted per ___________________________________
year
(G) I.C.U./H.D.U. Facilities:
1. ICU/HDU facilities: Present___________ Not present _________
2. No. of ICU beds ______________________________________
3. Trained
Nurses ______________________________________
Technicians ______________________________________
4. Name and number of
equipments in ICU _____________________________________
(H) Laboratory Facilities:
a. Biochemistry
1. No. of permanent staff with their designations.
2. No. of investigations carried out in the Dept.
b. Microbiology
1. No. of permanent staff with their designations.
2. No. of investigations carried out in the Dept.
c. Pathology
1. No. of permanent staff with their designations.
2. No. of investigations carried out in the Dept.
(I) Imaging Services:
1. No. of permanent staff with their designations.
2. Names of the investigations carried out in the Dept
3. HLA Laboratory Facility:
4. PRA Testing Facility
5. Name and No. of equipment available.
(J) Haematology Services:
1. No. of permanent staff with their designations.
2. Names of the investigations carried out in the Dept.
3. Name and No. of equipment available.
(K) Blood Bank Facilities:
Provide screened blood and blood products
(L) Dialysis Facilities:
(M) Names of Non-transplant Organ Harvesting Team:
1. Medical Superintendent __________________
2. Anaesthetist _________________
3. Neurologist _________________
4. Neurosurgeon _________________
5. Cardiologist ________________
6. Nephrologist ________________
7. Medical Gastroenterologist ________________
8. General Medicine_______________
9. pulmonologist ___________________
10. CT Surgeon _______________________
11. Urologist _______________________
12. Surgical Gastroenterologist _________________
13. Medico social worker __________________
14. Transplant coordinator _________________
15. Nursing staff __________________
`(N) Brain Death Declaration Team:
1. Medical Superintendent _____________________
2. An independent Medical
Practitioner nominated by Medical Superintendent
of the hospital/AACT _____________________
3. A Neurologist or Neurosurgeon nominated by Medical
Superintendent of the _____________________hospital/AACT
4. The doctor on-duty treating the patient _____________________
(O) Other Supportive Facilities:
Data about other facilities available in the hospital.
The above said information is true to the best of my knowledge and I have
no objection to any scrutiny of our facility by authorized personnel. A Bank
Draft/Cheque of Rs. 5,000 is being enclosed.
Head of the Institution
Note: D.D in favour of “NIMS JEEVANDAN SCHEME”.
